Anderson James G, Abrahamson Kathleen
Department of Sociology, Purdue University, West Lafayette, IN, USA.
Stud Health Technol Inform. 2017;234:13-17.
Recent studies of medical errors have estimated errors may account for as many as 251,000 deaths annually in the United States (U.S)., making medical errors the third leading cause of death. Error rates are significantly higher in the U.S. than in other developed countries such as Canada, Australia, New Zealand, Germany and the United Kingdom (U.K). At the same time less than 10 percent of medical errors are reported. This study describes the results of an investigation of the effectiveness of the implementation of the MEDMARX Medication Error Reporting system in 25 hospitals in Pennsylvania. Data were collected on 17,000 errors reported by participating hospitals over a 12-month period. Latent growth curve analysis revealed that reporting of errors by health care providers increased significantly over the four quarters. At the same time, the proportion of corrective actions taken by the hospitals remained relatively constant over the 12 months. A simulation model was constructed to examine the effect of potential organizational changes resulting from error reporting. Four interventions were simulated. The results suggest that improving patient safety requires more than voluntary reporting. Organizational changes need to be implemented and institutionalized as well.
近期有关医疗差错的研究估计，在美国，医疗差错每年可能导致多达25.1万人死亡，这使医疗差错成为第三大死因。美国的差错率显著高于加拿大、澳大利亚、新西兰、德国和英国等其他发达国家。与此同时，报告的医疗差错不到10%。本研究描述了对宾夕法尼亚州25家医院实施MEDMARX用药差错报告系统的有效性进行调查的结果。收集了参与医院在12个月内报告的17000起差错的数据。潜在增长曲线分析显示，医疗服务提供者报告的差错在四个季度中显著增加。与此同时，医院采取纠正措施的比例在12个月内保持相对稳定。构建了一个模拟模型来检验差错报告可能导致的组织变革的影响。模拟了四种干预措施。结果表明，提高患者安全需要的不仅仅是自愿报告。还需要实施组织变革并将其制度化。
